The wisdom of surgical interference in haematemesis and melaena from gastric and duodenal ulcer : being a paper read in the Section of Surgery at the Annual Meeting of the British Medical Association, held at Portsmouth, August, 1899 / by G.E. Armstrong.

  • Armstrong, George E., 1854-1933.
Date:
1899
Catalogue details

Licence: Public Domain Mark

Credit: The wisdom of surgical interference in haematemesis and melaena from gastric and duodenal ulcer : being a paper read in the Section of Surgery at the Annual Meeting of the British Medical Association, held at Portsmouth, August, 1899 / by G.E. Armstrong. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    ture carried through the base of the ulcer, just beneath the opening in the wail of the vessel on a curved needle. This arrested the hasmorrhage completely. A row of additional sutures was carried across the lloor of the ulcer in such a manner tliat the floor of the ulcer was somewhat elev- ated'and the edges approximated. After closing the opening in the anterior wall of the stomach the abdomen was closed witliout drainage. Unfortunately this patient died from acute anremia tlie following day at 1 A.M. Among other things ij litre of normal saline solution was administered subcutaneously, and an equal quantity ver rectum. At the necropsy it was found that no bleeding had occurred after the operation. The following evening when I sat down quietly for that period of retrospection and introspection that, I fancy, is not foreign to the experience of any surgeon, I came to two con- clusions : First, that this woman’s life would in all probability have been saved if she had been operated upon after the second haemorrhage ; and, secondly, that the tone, the advice, given to-day in the medical and surgical literature was re- sponsible for the dfelay. I felt that had I another similar case early operation would save it. But, as Carlyle says, “ It is easy to be wise behindhand,” With a view to getting further information on this question of the operability of these cases, I asked Dr. Wyatt Johnson, Pathologist to the Montreal General Hospital, to give me ex- tracts from the reports of all necropsies performed on patients who had died from gastric hsemorrhage. From Dr. Johnston’s report I find that in a series of 2,000 necropsies, 15 or 0.75 per cent, died from hsemorrhage from the stomach. Of these 15 cases, in 5, or 33I per cent., the hsemorrhage was from a gastric ulcer; in 4, or 26I per cent., from an ulcer in the duodenum; in i from rupture of an cesophageal varix, secondary to thrombosis of the portal vein, atrophy and sar- coma of the liver; in i to rupture of an cesophageal vaiix secondary to cirrhosis of the liver; in 2 to leucocythaemia; and in 2 to aneurysms rupturing into the lower end of the oesophagus. Now I will in as few words as possible state just the con- dition found in each of these cases of gastric and duodenal ulcer: Case i.—Female, aged 40. Fatty and cirrhotic liver, atrophic spleen, no ascites, fibroid kidneys. About the middle of the lesser curvature an ulcer, almost circular, tliree-quarters of an inch in diameter, with sharply cut euges which are not raised. In the centre of the floor is an open artery, not plugged, and readily admitting a small probe. Case ii.—Male, aged 50. Chronic ulcer of the stomach, perforation, and haemorrhage. In the peritoneal cavity is half a gallon of thick dark-red fluid. Three inches from the pylorus is a large perforation in the anterior wall of the stomach, occurring in the base of an ulcer 6 cm. long by 2 cm. wide. A branch of the gastric artery ulcerated through having an orifice into which a small probe can be passed. Case hi.—Female, aged 20. Lower two-thirds of the cesophagus dilated, and on cutting it open a number of irregular elongated losses of sub- stance are seen; the strands of tissue between these look cicatricial. About the middle of the posterior wall of the stomach is a yellowish slough 6 mm. by 10 mm. in size, and extending 3 mm. to 4 mm. deep, reaching into the muscular coat. No plugged vessels detected. Case iv.—In the fourth case there was found an oval loss of substance on the lesser curvature, three inches from the pylorus; size, cm. by 2 cm. Edges round and clean cut, base made up of dense fibroid tissue. In this the ends of obliterated as well as open vessels are seen—the latter very numerous, four of these presenting gaping orifices. On injecting water into the gastric artery it flows in a tree scream from the lai'gest of these orifices. Case v.—The necropsy report of Dr. Elder’s case, already sufficiently reported. Case vi.—The report of a duodenal ulcer, unfortunately mislaid. Case vii.—Duodenal ulcer, oval in shape, situated immediately outside the pyloric ring, i in. long in the axis of the gut and } in. wide; deep, with rounded edges, which are much undermined. Immediately in the